Often a Sick Child: When to Start Worrying
Doc. Laimutė Vaidelienė
LSMU Children's Diseases clinic
Keywords: frequently ill child, cough, allergic rhinitis, adenoiditis, sinusitis, asthma, immunodeficiencies, children.
Many children, upon starting to attend a group, often get sick. Frequent respiratory tract infections are often caused by an immature immune system, anatomical and physiological peculiarities of a child's body, and social factors. These children often have chronic infection foci in the nasopharynx, diagnosed with allergies. It is important for the doctor to distinguish whether frequent infections are not a sign of a serious chronic respiratory disease, as the course of most chronic lung diseases greatly depends on early diagnosis and timely treatment.
When examining frequently ill children, it is important to rule out the most common causes of respiratory disease recurrences: recurrent viral infections, chronic infection foci in the nasopharynx, allergic diseases (bronchial asthma and allergic rhinitis), and gastroesophageal reflux disease (GERD). Additionally, it is necessary to determine whether the course of respiratory tract infections is normal, whether the treatment given was appropriate, how the child feels during remission, and if the child is developing normally. If the diseases can be described as severe, persistent, unusual, recurrent, caused by unusual pathogens, and if there have been severe chronic diseases or early deaths in the family, such children must be examined for possible rare chronic diseases: purulent lung diseases, infections, anatomical defects in the respiratory tract, immunodeficiencies.
Unfortunately, there are currently no reliable, evidence-based research and diagnostic methods for all possible clinical cases, so we hope that the general recommendations based on the experience of internationally recognized specialists provided in this article will be useful for practicing doctors.
Introduction
Every family doctor caring for children encounters frequently ill children. Respiratory tract (RT) infections are the most common pathology in children and a reason for seeking medical attention. About 25% of infants and 18% of 1-4-year-old children suffer from recurrent respiratory tract infections [1,2]. These diseases account for 75% of all prescribed medications, with antibiotics being the most commonly prescribed. According to a study by G. Urbonas, when treating acute viral RT infections, antibiotics are prescribed in up to 40% of cases during the first visit [19]. This is done due to pressure from the patient's parents, inability to observe the patient, in order to protect against severe bacterial infections, and the inability to perform diagnostic tests (blood tests and CRP). However, in many cases, these are common, uncomplicated, although sometimes frequently recurring, viral respiratory tract infections, for which antibacterial treatment is irrational and unjustified.
Therefore, it is crucial to identify the individual causes of frequent RT infections in children, risk factors, and provide appropriate treatment as early as possible, and if it is ineffective, refer to specialist consultation.
Factors influencing frequent childhood respiratory tract infections
The frequency of respiratory tract infections depends on various factors, primarily on the maturity of the immune system, anatomical and physiological characteristics of children's respiratory tract.
Anatomical and physiological features of children's bodies that determine the severity and frequency of RT infections:
• The nasal passage is narrow and short, so the inhaled air is less warmed. The mucosa is swollen, rich in blood vessels, so even a slight inflammation causes significant swelling. The nasal sinuses are narrow, so inflammation lasts longer.
• Lymphoid tissue of the nasopharynx – adenoids, prone to hypertrophy at the age of 2–7, especially in allergic and immunocompromised children. Enlarged adenoids cause nasal obstruction, can interfere with the opening of the Eustachian tube. This disrupts ventilation of the middle ear cavity, leading to a faster development of inflammation of the ears. Viral infections in the nasopharynx last longer and can be complicated by bacterial infections.
• The auditory (Eustachian) tube, connecting the nasopharynx with the middle ear, is horizontal, short, and wide, making it easier for nasal infection to enter the ear and complicate middle ear inflammation.
• Paranasal sinuses (maxillary, sphenoidal sinuses) become clinically significant at > 5 years old, while frontal sinuses are significant only at > 10 years old, therefore sinusitis is characteristic of older children. Younger children may suffer from ethmoidal sinus inflammation.
• The funnel-shaped larynx is the narrowest part of a child's respiratory tract. The laryngeal mucosa is soft, with many blood vessels, so during inflammation, laryngitis clinical symptoms occur, and stenosis can develop.
• The bronchi are narrow, with a delicate mucosa and a wide network of blood vessels. Inflammation causes mucosal swelling and rapid development of bronchial obstruction.
• The mucosa of the respiratory tract in children prone to allergies swells more, so when they have laryngitis or bronchitis, obstruction develops faster, and the disease recurs more frequently.
Immature immune system leads to a weaker general and local immune response to infections and can be the cause of their recurrence:
• The immune response of infants and young children is 2–3 times weaker than that of adults;
• The immune response is more often of the Th2 type – infection triggers an allergic inflammatory response and predisposes children to allergic respiratory diseases;
• Until the age of 3 months, humoral factors of local immunity (IgM, IgA, IgG) are practically absent, reaching adult levels only at 4–6 years old.
The child's social living conditions, frequency of contact with infections, and attendance in groups [3,13,14] are of great importance. Many children, upon starting to attend a group setting (kindergarten), often begin to suffer from respiratory infections. Studies show that a child who starts attending kindergarten can get sick 12–14 times a year [1,3,9,10,11].
These children not only get sick themselves but also spread infections to the environment, making group settings like kindergartens, schools, daycare centers, public gathering places (shopping centers), and even from older siblings, the easiest places to get infected. Children exposed to passive smoking and infants not breastfed are more susceptible to infections.
If a four-year-old child attending kindergarten gets sick with respiratory infections every month and at least once a week, it may seem like the child is constantly ill. The parents of such children are always concerned about their child's immune status, but frequent illness in these children is usually due to physiological immaturity of the immune system rather than a true immunodeficiency.
Which patient needs a more thorough examination
Frequently ill children complain of prolonged or constant runny nose, recurrent or persistent cough, worsened breathing, wheezing and shortness of breath; sputum, fever (or low-grade fever), and feeling unwell. These symptoms are characteristic of many acute and chronic respiratory diseases.
First of all, it is recommended to consider the most common causes: common respiratory tract infections (viral). Usually, viral respiratory tract infectionIt usually lasts about 7-8 days, but a child can be ill for up to 2 weeks. A healthy child can have symptoms of viral infections up to 6 months per year. Early attendance at a kindergarten increases the frequency of these infections, which can scare young parents. However, most children with recurrent uncomplicated viral infections < 15 times per year should not be treated with antibiotics and additionally tested [1,3].
It is very important to distinguish a group of children who need further examination and pathogenetic treatment. Consultation with specialists may be necessary for children with recurrent lower respiratory tract viral and bacterial infections, suspected chronic infection foci in the nasopharynx, and GERD [3,12]. The indications for early examination of a frequently ill child are presented in Table 1.
Table 1. Indications for early examination of a frequently ill child [3]
|
Conditions where a frequently ill child needs further examination: Aspects of medical history indicating the need for further examination of the disease: |
Children with identified conditions or symptoms requiring additional examination should be examined for many possible diseases, as listed in Table 2. About 30% of frequently ill children are diagnosed with allergy, leading to increased susceptibility to respiratory tract infections, recurrent rhinitis, rhinosinusitis, laryngitis, or obstructive bronchitis [15]. Therefore, it is first recommended to rule out or confirm those diseases that occur most frequently: infection foci in the nasopharynx, allergy, and GERD.
Table 2. Differential diagnosis of common diseases in frequently ill children suspected of having a chronic respiratory organ disease
| Upper respiratory tract diseases | Lower respiratory tract diseases |
|
• Infection focus in the nasopharynx: • Allergy: allergic rhinitis • GERD Consultation with an ENT physician is required |
• Allergy: bronchial asthma • Tuberculosis Consultation with a pediatric pulmonologist-allergist is required |
When to suspect a persistent nasopharyngeal infection
In recent years, the focus of infection in the nasopharynx has become one of the most important causes of frequent illnesses in preschool-aged children. Acute, recurrent, or chronic adenoiditis, rhinosinusitis, tonsillitis, or otitis should be suspected in every child exhibiting the following symptoms [4]:
• Constant, recurrent runny nose;
• Stuffy nose;
• Purulent secretions;
• Postnasal drip;
• Recurrent middle ear infections (otitis);
• Cough, especially at night;
• snoring;
• Recurrent bronchitis, pneumonia;
• Effective antibiotic treatment;
• Ineffective asthma prophylactic treatment.
These children should be consulted by an ear-nose-throat specialist, who can help diagnose and manage GERD, which often presents with atypical, chronic laryngopharyngeal symptoms [5]:
• Choking;
• Wheezing;
• Throat clearing;
• Feeling of a "lump" in the throat;
• Cough;
• Mucorrhea (excessive nasal secretions);
• Unpleasant breath odor.
It is also important to remember that adenoid hypertrophy, frequent rhinosinusitis, and ear infections may be associated with allergic inflammation of the nasal mucosa. Therefore, these children should be referred to a pediatric allergist for evaluation of possible allergic rhinitis.
After ruling out common diseases, it is worth noting that recurrent rhinosinusitis or otitis may also be indicative of rare but very important pediatric diseases: cystic fibrosis (CF), primary ciliary dyskinesia, immunodeficiency states.
When to suspect a chronic lower respiratory tract disease
Bronchial asthma is the most common chronic lower respiratory tract (LRT) disease, which is considered whenever a child experiences episodes of wheezing, coughing, or obstructive bronchitis. Bronchial asthma is likely when:
• Sensitization to inhaled or food allergens is detected;
• There is a positive family history of allergies;
• Bronchial obstruction is triggered by allergens and other environmental factors, without clear signs of respiratory infection;
• Bronchodilator therapy is effective;
• Changes in spirometry and bronchial hyperreactivity are detected in older children.
This disease is so extensively discussed and written about that it is suspected in almost every child with a cough or bronchitis. After a diagnosis of childhood bronchial asthma, other upper (adenoiditis, allergic rhinitis, rhinosinusitis) and lower respiratory tract diseases (post-infectious cough, anatomical defects of the respiratory organs, foreign bodies in the respiratory tract) may also be present.
Post-infectious cough may persist after an acute respiratory tract infection. In young children who have had bronchiolitis, coughing, worsened breathing, and bronchial obstruction can persist for months or even years. Following pertussis (Bordetella pertussis) or mycoplasmal infection, due to impaired mucociliary clearance and increased bronchial reactivity, paroxysmal coughing may persist for 2–6 months [2,3].
Respiratory foreign body should be suspected until a previously healthy child begins to experience symptoms of AKT disease after choking. Diagnosis is complicated by the fact that the patient or their relatives often deny choking incidents. Additionally, food products, plastic objects, and other non-radiopaque materials are not visible on a chest X-ray. If there is even the slightest suspicion of a foreign body, bronchoscopy must be performed. It is important to remember that local inflammation, impaired lung function, and persistent cough may persist long after the foreign body has been removed.
Anatomical defects of the respiratory organs are most often congenital, but can also be acquired after trauma or medical interventions. Congenital pathology (e.g., laryngo-, tracheomalacia) in early age may go undetected because newborns and infants in the first months do not experience significant physical stress, and symptoms may not be visible at rest. Only as the child grows or during the first respiratory infection, symptoms such as stridor, wheezing, or grunting become apparent.
Bronchial stenosis or external compression can mimic severe asthma symptoms for many years and can only be diagnosed through bronchoscopy and a computed tomography scan of the chest.
Chronic purulent lung diseases, systemic diseases, immunodeficiencies can also manifest with asthma-like symptoms, affecting up to 10% of children [15]. However, viral infections quickly turn into bacterial pneumonia and chronic productive cough. The British Thoracic Society (BTS) defines a chronic cough as lasting more than 8 weeks [3]. The speed of examining a coughing child is determined not by the duration of non-productive cough but by the overall condition of the child: if the child feels unwell, they must be examined immediately. According to a study conducted in the United Kingdom, prolonged isolated productive cough in children is rarely caused by bronchial asthma [3, 20]. The most common cause of such a cough in children is bacterial bronchitis [3,16]. However, the authors of this study recommend examining children who cough productively for a long time for other purulent lung and other diseases [17].
Chronic purulent lung diseases in children
Chronic purulent lung diseases in children belong to the category of rare diseases, but they are very important as they lead to constant lung infections, nutritional and growth disorders, and chronic respiratory failure. This group of diseases includes cystic fibrosis (CF), primary ciliary dyskinesia (PCD), idiopathic bronchiectasis, immunodeficiencies, and other rare diseases.
Chronic purulent lung disease should be suspected in a frequently ill child when:
• there is a constant or recurrent productive cough with purulent sputum;
• severe pneumonia recurs, tends to prolong, and is resistant to conventional treatment;
• asymmetrical or local changes in the lungs are detected during remission;
• atypical pathogens are identified;
• the child has poor growth.
There are many congenital and acquired immunodeficiencies that require diagnosis by experienced immunologists. However, these children often first visit pediatric pulmonologists. It is important to remember that primary congenital immunodeficiencies in children are rare (1:10,000), so immunological testing should only be considered after ruling out more common diseases. Most frequently ill children do not have immunodeficiency. If it is diagnosed, it is usually a deficiency of immunoglobulins [14,15].Immunodeficiencies are characterized by the description "SPUR" provided at the beginning of the article - severe, persistent, unusual, and recurrent diseases. They are accompanied by hepatosplenomegaly, arthropathies, growth disturbances, and a family history of immunodeficiency. Not only neutropenia but also lymphopenia (<2.8 x 109/l) can be a sign of severe combined immunodeficiency [3,18]. According to a study conducted in the United Kingdom, immunodeficiency was identified in 88% of newborns up to 6 months of age, started to be investigated after the first episode of lymphopenia. The first symptoms of infection appeared in them on average within 5 weeks. In the presence of immunodeficiency, upper respiratory tract infections most commonly recur, but children can also suffer from other diseases [3,14,15]:
• 8 or more otitis media per year;
• 2 or more severe sinus infections (e.g., requiring intravenous antibiotic therapy) per year;
• persistent oral or cutaneous candidiasis;
• ineffective continuous antibiotic therapy for 2 or more months;
• need for intravenous antibiotics to treat infection;
• recurrent bronchitis, pneumonia, abscesses, and bronchiectasis.
The etiology of infections largely depends on the type of immunodeficiency: encapsulated microorganisms, Pneumocystis jiroveci, and enteroviruses are characteristic of antibody deficiency. Chronic granulomatous diseases manifest with Burkholderia cepacia infections, and disseminated nontuberculous mycobacteria can be a consequence of gamma interferon/IL12 deficiencies.
Immunological tests (immunogram, immunoglobulins and their subclasses, response to vaccines, complement tests, HIV test), chest CT scan, bronchoscopy, and bronchial lavage tests are often sufficient to diagnose immunodeficiency. In case of an unclear diagnosis, a lung biopsy is recommended.
Summary
• Early socialization of a child and attending daycare increase the risk of frequent respiratory diseases.
• A well-collected medical history and adequate patient examination are key to managing frequently ill children.
• It is important to rule out the most common causes of recurrent respiratory infections: common viral infections, allergies (bronchial asthma, allergic rhinitis), and GERD.
• Do not forget that frequent illnesses are often related to upper respiratory tract pathology and chronic infection foci in the nasopharynx. Therefore, a child with frequent illnesses should be consulted by an ENT specialist.
• Pay attention to the child's physical development, environmental factors, and concomitant pathologies.
• In case of suspected chronic respiratory disease, the child should be consulted by an experienced pediatric pulmonologist-allergist.
• Many rare chronic respiratory diseases can be easily diagnosed, the most important thing is to suspect them.
• Immunodeficiency is not a common cause of recurrent respiratory infections - it is recommended not to overestimate the importance of immune system tests and immunostimulants.
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